Aesthetic Solution for Subgingivally Fractured Permanent Incisors Report of 3 cases

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1 CLINICAL CASES Dent. Med. Probl. 2004, 41, 2, ISSN X LESZEK SAWICKI, MACIEJ BODAL, KATARZYNA EMERICH POPLATEK, BARBARA ADAMOWICZ KLEPALSKA Aesthetic Solution for Subgingivally Fractured Permanent Incisors Report of 3 cases Rozwiązanie estetyczne w poddziąsłowych złamaniach stałych zębów siecznych opis 3 przypadków Department of Paediatric Dentistry Medical University of Gdansk, Poland Abstract A simple, clinical method utilizing new biomechanical construction is proposed. The technique is addressed to sub gingival fractures of anterior teeth, located in the aesthetic region. In that case, treatment options up to now, are li mited to: forced eruption, surgical intraalveolar transplantation, surgical crown elongation or tooth extraction with bridge or implant placement. The vertical extrusion offers a method of conserving nonrestorable tooth. It allows for the state of the art preparation of the tooth, remaining gingival biological width and bone margin intact. Three cases are reported. All of them represent a challenge for a general practitioner. As far as aesthetic aspect of those cases is concerned, forced eruption is the treatment of choice. This article presents an alternative, simple, reliable technique, that could be applied in each dental office. It allows for aesthetic provision during the extrusion period, predictable results and cost effective treatment (Dent. Med. Probl. 2004, 41, 2, ). Key words: tooth fracture, forced eruption. Streszczenie Zaproponowano prostą metodę kliniczną wykorzystującą nowe rozwiązanie biomechaniczne. Procedura może być stosowana w poddziąsłowych złamaniach koronowo korzeniowych zlokalizowanych w strefie estetycznej przed sionka jamy ustnej. Dotychczas w podobnych przypadkach leczenie ograniczało się do ekstruzji ortodontycznej, autotransplantacji zęba lub chirurgicznego wydłużenia korony zęba. Kontrolowana ekstruzja zęba pozwala na uzyskanie dostępu do poddziąsłowych struktur zęba, umożliwia prawidłową preparację korzenia przy jednocze snym utrzymaniu biologicznej szerokości dziąsła, bez naruszenia brzegu kości wyrostka zębodołowego. Opisano 3 przypadki pourazowe siekaczy, które stanowią znaczący problem leczniczy dla ogólnie praktykującego lekarza stomatologa. Uzyskanie dobrego efektu estetycznego podczas całego okresu leczenia wraz z końcową odbudową protetyczną wskazuje, że kontrolowana ekstruzja dowierzchołkowego fragmentu złamanego korzenia zęba może być metodą z wyboru. Praca prezentuje alternatywne postępowanie, obejmujące skuteczną i prostą procedurę kli niczną, umożliwiającą wykonanie zabiegu w każdym gabinecie stomatologicznym, z zachowaniem estetyki, prze widywalnością powodzenia leczenia i niskim kosztem (Dent. Med. Probl. 2004, 41, 2, ). Słowa kluczowe: złamanie zęba, kontrolowana ekstruzja. The tooth fracture located below the gingival attachment or bone crest is a very difficult restora tive problem. The preservation of gingival biolog ic width is critical for the long term success of a restored tooth [1]. The restorative, functional and aesthetic needs should have been balanced with demands of a healthy periodontium. Otherwise subgingival placement of the margin of a crown or restoration will lead to the chronic gingival inflammation, loss of a clinical attachment, bone pockets and gingival recessions [2 4]. The care must be taken to involve as little of the sulcus as it is possible. On the basis work of Gargiulo et al., the general agreement that about 3 mm should be left between the margin of a restoration and the alveolar bone was proposed [4 7]. Approaching tooth fractures located near the alveolar bone, the practitioner has 3 options. The

2 282 L. SAWICKI et al. first one is tooth removal followed by implant place ment or porcelain fixed partial denture. Another option is crown surgical elongation. However, this procedure often leads to acceptable results and should be considered in non aesthetic region, where the function is of the major importance. Forced erup tion as a method of treating nonrestorable teeth, in that case, seems to be the treatment of choice. The vertical extrusion was first reported by Heithersay (1973) and Ingber (1975) [5, 8]. As an extrusion is considered the easiest orthodontic tooth movement, it gives the possibility to achieve excellent results with good prognosis and low risk of a relapse [3, 5, 9 11]. Despite many advantages, the technique is rarely used. This article describes own modification of common procedure using simple, new construc tion of office made orthodontic unit. It allows for the aesthetic provision during the extrusion period, pre dictable results and cost effective treatment. Fig. 1. Case 1. Clinical status of subgingival fracture of tooth 21 Ryc. 1. Przypadek 1. Obraz kliniczny złamania pod dziąsłowego zęba 21 Description of Cases Case 1 A patient A. R., aged 22, reported to the Department of Paediatric Dentistry with a deep, subgingival fracture in the aesthetic region of a maxillary left central incisor (Fig. 1). The clinical and radiological evaluation revealed improper root canal treatment. Under the local anesthesia, the entire crown was removed and re endo therapy was completed. The canal was filled with warm gutta percha condensation technique using Obtura II gun. The fragment of a fractured crown was bonded to the adjacent teeth, presenting good aesthetics. During the next visit, 4 days later, the patient s own temporary crown was removed and standard post Radix Anchor was temporarily cemented in the root canal. The elastic loop was attached to the head of the post with the dental floss. The fragment of a fractured crown was used once more. The crown was attached to the adjacent teeth with the acid etch composite resin, which created a passive end for the elastics. Then elastic loop was activated. It was stretched and moved from palatal side of the tem porary crown, via the incisal edge, to the labial side of the same crown (Fig. 2). Finally, activated elastic loop was bonded to the acid etched labial side of the crown with the flowable composite (Fig. 3). The patient with aesthetically acceptable, temporary and active appliance was sent home. She was scheduled for recall visits every 4 days. At that time, elastic loops were changed, sulcular incisions and radio logical assessments were made. After 25 days of controlled extrusion, 3.5 mm of root were exposed with the average speed 1 mm per week. The extrud Fig. 2. Case 1. Fractured crown of tooth 21 appropria tely prepared and attached to adjacent teeth with com posite resin serving as an extrusion bar and aesthetic provision. Elastic loop stretched and bonded to the la bial surface of the extrusion bar Ryc. 2. Przypadek 1. Odpowiednio przygotowana odła mana korona zęba 21 zespolona z sąsiednimi zębami za pomocą żywicy kompozytowej jako element szynujący podczas ekstruzji zęba stanowiący tymczasowe uzupeł nienie estetyczne. Naciągnięta pętla elastyczna zostanie przymocowana do powierzchni wargowej szyny Fig. 3. Case 1. Radiological image of tooth 21 during extrusion Ryc. 3. Przypadek 1. Obraz radiologiczny zęba 21 podczas wydłużania

3 Aesthetic Solution for Subgingivally Fractured Permanent Incisors 283 Fig. 4. Case 1. Radiological image of tooth 21 during retention period Ryc. 4. Przypadek 1. Obraz radiologiczny zęba 21 w okresie retencji Fig. 7. Case 2. Radiological image of tooth 41. Root canal was temporarily filled with calcium hydroxide paste and a standard post placed for extrusion Ryc. 7. Przypadek 2. Obraz radiologiczny zęba 41. Kanał zęba został czasowo wypełniony pastą wodoro tlenkowo wapniową oraz zastosowano standardowy wkład pozwalający na ekstruzję Fig. 5. Case 1. Clinical status of final porcelain recon struction. A slight intrusion of tooth 21 is visible Ryc. 5. Przypadek 1. Stan kliniczny po założeniu osta tecznego uzupełnienia porcelanowego. Widoczna jest nieznaczna intruzja zęba 21 Fig. 8. Case 2. Composite material used as an extru sion bar and aesthetic provision Ryc. 8. Przypadek 2. Materiał złożony zastosowany jako szyna podczas ekstruzji korzenia stanowiący jed nocześnie tymczasowe uzupełnienie estetyczne Fig. 9. Case 2. Radiological image of extruded root of tooth 41 after endodontic therapy Ryc. 9. Przypadek 2. Obraz radiologiczny po ekstruzji korzenia zęba 41 po leczeniu endodontycznym Fig. 6. Case 2. Clinical status of fracture of tooth 41 Ryc. 6. Przypadek 2. Obraz kliniczny złamania zęba 41 ed tooth was retained for 5 weeks (Fig. 4). A com posite crown was fabricated and applied as a retain er. After 5 weeks of the stabilization period, the temporary crown was removed, the extrusion post was unscrewed with a hemostat. The tooth mobility was normal. The final restoration, a porcelain fused to metal crown was finished a week later. Four months later, the function and aesthetics were still good. The patient did not report any com plaints. The clinical evaluation revealed some Fig. 10. Case 2. Clinical status of cemented full ceramic crown Ryc. 10. Przypadek 2. Stan kliniczny po założeniu ko rony porcelanowej

4 284 L. SAWICKI et al. minor root intrusion of about 0.5 mm (Fig. 5). Two months later no further intrusion was observed. Radiological assessment showed lack of root resorption. The function and esthetics were still good. During one year recall visit, good aesthetics, stable crown position and function were observed. Radiological evaluation showed no pathological response in the root area. Case 2 A 19 year old boy, P. S., reported to the Department of Paediatric Dentistry with a compli cated crown fracture of two maxillary central incisors and oblique crown root fracture of lower right central incisor (Fig. 6). Upper central incisors were endodontically treated and restored using bonded composite restoration (tooth 21) and porce lain crown (tooth 11). The radiological examination of the lower fractured incisor revealed an extensive, complicated oblique crown root fracture, extending about 1 mm distally below the alveolar crest (Fig. 7). The patient was informed about the possibility of saving the fractured tooth using the forced eruption technique. During the next visit, under the local anesthesia, pulpectomy of the lower right central incisor was performed. The root canal was prepared, rinsed with sodium hypochlorite solution, dried and filled with calcium hydroxide dressing. The final gutta percha obturation of the root canal was delayed until the proper, dry condition of the opera tion field was achieved. An artificial composite crown was fabricated and bonded to the adjacent teeth, replacing temporarily the missing tooth (Fig. 8). At the next visit, temporary crown was removed and stainless steel hook was cemented in the root canal as an anchorage for the elastic loop. Fabricated composite crown was attached to the adjacent teeth with the acid etch composite resin. The activation of the elastics was done in the same way as in case 1. Activated elastic loop was bonded to the acid etched labial side of the crown with the flowable composite. To prevent ripping of the elas tics, the same, small notch on the incisal edge of fab ricated crown was made. The patient with aestheti cally acceptable, temporary and active appliance was sent home. The elastic loops were changed and sulcular incisions were made every 4 days. The extrusion took 20 days, resulting in tooth movement of about 3.5 mm, which gave approximately 1.2 mm per week. The extruded tooth was retained for 8 weeks using the same fabricated composite crown. Finally, after retainer and hook removal, conven tional endodontic therapy was completed (Fig. 9). A week later fibre glass post was cemented, crown preparation was performed and the impressions were taken. 13 weeks after the initial visit, the miss ing tooth was restored with the full ceramic crown (Fig. 10). At a recall visit, a month later, despite slight mobility of the extruded tooth, the patient did not report any complaints. The X ray showed absence of any pathological response (Fig. 11). Two months after extrusion function and esthetics were still good. The tooth mobility was normal. Case 3 21 year old patient, W. W., entered the Paediatric Department, reporting pain and tooth mobility (Fig. 12). During the clinical examination, a horizontal root fracture of the upper central left incisor was diagnosed (Fig. 13). Under the local anesthesia, mobile tooth fragment was removed (Fig. 14) and the X ray was taken. Radiological evaluation confirmed clinical diagnosis showing the fracture line approximately 3 mm under the bone crest. At the same visit, pulpectomy was performed, root canal was cleaned and shaped with endo files and disinfected using 2.5% sodium hypochlorite solution. Like in the case 2, after drying, the root canal was temporarily filled with calcium hydrox ide dressing, until proper condition for final gutta percha obturation was achieved. The missing tooth was replaced with the prepared crown of removed incisor. It was bonded to the adjacent teeth and splinted with two teeth on each side using the 1 mm diameter round stainless steel wire. A week later, temporarily crown was removed and standard post was cemented (Fig. 15). The elastic loop was attached to the head of the post with the dental floss. The fragment of a fractured crown was used once more. It was thinned and shortened in order not to touch root fragment and post, otherwise the extru sion would not be possible. The crown was attached to the adjacent teeth with the acid etch composite resin. The activation of the elastics was done according to the same, earlier applied protocol. The patient, with active construction of mini orthodontic appliance was sent home. He was scheduled for Fig. 11. Case 2. Radiological image of reconstructed tooth 41 Ryc. 11. Przypadek 2. Obraz radiologiczny odbudowa nego zęba 41

5 Aesthetic Solution for Subgingivally Fractured Permanent Incisors 285 Fig. 12. Case 3. Clinical status of fractured tooth 21 Ryc. 12. Przypadek 3. Obraz kliniczny złamania zęba 21 Fig. 15. Case 3. Radiological image of tooth 21 during orthodontic extrusion Ryc. 15. Przypadek 3. Obraz radiologiczny zęba 21 podczas ekstruzji ortodontycznej Fig. 13. Case 3. Radiological image of tooth 21. Horizontal root fracture line is located approximately 3 mm under the bone level Ryc. 13. Przypadek 3. Obraz radiologiczny zęba 21. Pozioma linia złamania zlokalizowana jest około 3 mm poniżej brzegu kości Fig. 16. Case 3. Radiological image of tooth 21 after endodontic therapy Ryc. 16. Przypadek 3. Obraz radiologiczny zęba 21 po leczeniu endodontycznym Fig. 14. Case 3. Clinical status of removed mobile tooth fragment Ryc. 14. Przypadek 3. Obraz kliniczny fragmentu zła manego zęba poza jamą ustną Fig. 17. Case 3. Clinical status of reconstructed tooth immediately after cementation of full ceramic crown Ryc. 17. Przypadek 3. Stan kliniczny odbudowanego zęba bezpośrednio po zacementowaniu korony porce lanowej recall visits every 4 6 days. At that time, elastics loops were changed, sulcular incisions and radio logical assessments were made. After 28 days of controlled extrusion, the appliance was removed. The root was exposed approximately 5 mm with average speed of 1.2 mm per week. The extruded incisor was stabilized for 3 months. During the extrusion and retention period patient was provided with the aesthetic crown fabricated from his own fractured tooth. After 12 weeks of the stabilization, retainer and standard post were removed. Classic endodontic therapy was completed, filling the root canal with gutta percha (Fig. 16). One week later fibre glass post was cemented and impressions were taken. After another 7 days, a final full ceramic restoration was placed (Fig. 17). At a control visit, one month later, function and aesthetics were good. The patient did not report any complaints.

6 286 Discussion Before starting with forced eruption, a few fac tors should be considered. The most important is crown to root ratio which shall remain at least 1 : 1. Root extrusion, when compared to surgical crown elongation maintains more ideal proportions: it decreases root length remaining crown length unchanged [5, 8, 11, 12]. Other factors like root morphology, tooth localization, its periodontal sta tus and the aesthetics needs are also of great impor tance [13]. When concerning aesthetics, the clini cian should also remember that a root diameter decreases at the end of the extrusion [5]. Proper contouring of final restoration becomes then a very important issue. Patients own fractured crown, used in case 1 and 3, or like in case 2 fabricated compos ite crown, offers several advantages. It is an excel lent aesthetic temporary restoration, very useful in extrusion and retention period. It is also an impor tant part of the biomechanical construction which allows for retaining tooth s original position. A tem porary crown also prevents lateral movement of the L. SAWICKI et al. adjacent teeth during the extrusion [12]. Eruptive tooth movement also results in coronal shift of the supporting connective tissue attachment and alveo lar bone [5, 6, 8, 11, 12]. To prevent that, a sulcular incision is necessary. Such incision relieves tension created by the stressed gingival fibres, that might lead to the possible relapse problem. The stabiliza tion period of 8 to 10 weeks seems to be suitable for achieving predictable results [9, 13]. 5 weeks reten tion period, in case 1, was inadequate, leading to unexpected minor intrusion of the treated incisor of about 0.5 mm. On that basis, we suggest to stabilize the extruded tooth at least for 2 months. New biomechanical construction presents a simple, reliable technique for single tooth extru sion. It could be applied in each dental office with out necessity of referring patient to the orthodontist. It also requires a minimum of specialized materials or orthodontic skills. It gives a chance of saving very often diagnosed nonrestorable tooth. As far as aesthetic aspect of those cases were concerned, forced eruption was the treatment of choice. References [1] PADBURY A., EBER R., WANG H. L.: Interactions between the gingiva and the margin of restorations. J. Clin. Pe riodontol. 2003, 30, [2] HAMILTON R. S., GUTMANN J. L.: Endodontic orthodontic relationships: a review of integrated treatment planning challenges. Int. Endod. J. 1999, 32, [3] SILNESS J.: Periodontal conditions in patients treated with dental bridges. III. The relationship between the loca tion of the crown margin and the periodontal condition. J. Periodont. Res. 1970, 5, 225. [4] TEJCHMAN H.: Ocena kliniczna, histochemiczna i bakteriologiczna przyzębia przy użytkowaniu koron złożonych (metalowo akrylowych) i akrylowych. Praca habilitacyjna, AM, Gdańsk [5] INGBER J. S.: Forced eruption. A method of treating nonrestoreable teeth periodontal and restorative considera tions. J. Periodontol. 1976, 47, [6] GARRETT G. B.: Forced eruption in the treatment of transverse root fractures. J.A.D.A. 1985, 111, [7] GARGIULO A. W., WENTZ F. M., ORBAN B.: Dimensions and relations of the dentogingival junction in humans. J. Periodontol. 1961, 32, 261. [8] HEITHERSAY G. S.: Combined endodontic orthodontic treatment of transverse root fractures in the region of the alveolar crest. Oral. Surg. 1973, 36, [9] IVEY D. W., CALHOUN R. L., KEMP W. B., DORFMAN H. S., WHELESS J. E.: Orthodontic extrusion: It`s use in resto rative dentistry. J. Prosthet. Dent. 1980, 43, [10] FOURNIER A.: Orthodontic management of subgingivally fractured teeth. J. Practical. Orthod. 1981, [11] HOVLAND E. J.: Horizontal root fractures. Treatment and repair. Dent. Clin. N. Am. 1992, 36, [12] OESTERLE L. J., WOOD L. W.: Raising the root. A look at orthodontic extrusion. J.A.D.A. 1991, 122, [13] JOHNSON G. K., SIVERS J. E.: Forced eruption in crown lengthening procedures. J. Prosthet. Dent. 1986, 56, Address for correspondence: Leszek Sawicki Department of Paediatric Dentistry Medical University of Gdansk Orzeszkowej Gdańsk Poland tel./fax: e mail: emerich@amg.gda.pl Received: Praca wpłynęła do Redakcji: r. Revised: Po recenzji: r. Accepted: Zaakceptowano do druku: r.